A nurse is assessing a bedridden patient and notes a reddened area on the sacrum that does not blanch when pressed. The skin is intact. Based on this finding, which stage of pressure ulcer should the nurse document?

Stage I

Stage II

Stage III

Stage IV

Answer and Explanation

The Correct Answer is A

A. Stage I. A Stage I pressure ulcer is characterized by intact skin with non-blanchable erythema. The affected area may feel warmer or firmer than surrounding skin.

B. Stage II. A Stage II pressure ulcer involves partial-thickness skin loss, often presenting as a shallow open ulcer or intact/blistered skin. Since the skin is still intact in this scenario, it is not Stage II.

C. Stage III. A Stage III pressure ulcer involves full-thickness skin loss with visible subcutaneous tissue but no exposed bone, tendon, or muscle. This does not match the description of an intact but reddened area.

D. Stage IV. A Stage IV pressure ulcer involves full-thickness tissue loss with exposed bone, tendon, or muscle. This is much more severe than the described case.

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Correct Answer is A

Explanation

A. "I will wear non-slip socks while in the hospital to reduce my risk of falling." Wearing non-slip socks provides better traction and reduces the risk of slipping, which is especially important for patients with osteoporosis who are at higher risk for fractures.

B. "I will place small rugs throughout my house to prevent slipping." Small rugs can be a tripping hazard and increase the risk of falls. Patients should be advised to remove loose rugs or secure them with non-slip backing.

C. "At home, I should not wear my glasses nearby to avoid missteps." Patients should always wear their prescribed glasses to ensure clear vision and reduce the risk of tripping over obstacles. Poor vision can contribute to falls.

D. "I don't need to do weight-bearing exercises because they won't help my bones." Weight-bearing exercises, such as walking and resistance training, help maintain bone density and reduce the risk of osteoporosis-related fractures.

A. Moderate level of pain B. Dependent edema distal to the cast C. Itching of the distal foot D. Inability to flex the toes of the casted foot

Correct Answer is D

Explanation

A. Moderate level of pain: Pain is expected after a fracture and casting. However, if pain is severe and unrelieved by medication, it may indicate compartment syndrome, which is an emergency. Moderate pain alone does not require immediate provider notification.

B. Dependent edema distal to the cast: Some swelling is expected due to reduced mobility and gravity-dependent positioning. Elevating the leg can help reduce swelling, but it does not require immediate provider notification.

C. Itching of the distal foot: Itching is a common, non-emergency side effect of casting. Clients should be advised not to insert objects inside the cast to relieve itching.

D. Inability to flex the toes of the casted foot: Inability to flex the toes suggests potential neurovascular compromise or compartment syndrome, a medical emergency requiring immediate intervention to prevent permanent nerve or muscle damage. The provider must be notified immediately.

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A nurse is assessing a bedridden patient and notes a reddened area on the sacrum that does not blanch when pressed. The skin is intact. Based on this finding, which stage of pressure ulcer should the nurse document?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is educating a patient with osteoporosis about fall prevention strategies at home and in the hospital. Which statement by the patient indicates a correct understanding of the teaching?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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